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Malnourishment in India

We as Indians like to prophesie on our fate to become a superpower in 21st century. Reports of international agencies and firms like IMF, World Bank, The Economist and Goldman Sachs by which virtue India is now being counted as newly industralised nation, part of emerging countries group BRICS and is being courted by countries like US, Russia, China, Japan etc with greater cooperation, investment and strategic tie-ups.

In this rosy picture of imagining India as superpower the hunger and malnourishment data on Indian citizens especially among children comes as rude shock to our elites. This has jarred elites so much that there has been paper by renowned economist like Aravind Panagariya which claimed the stunting of children in India is not due to malnourishment but genetic reasons. As country we hold the dubious record of malnourishment figures being below sub-saharan Africa. Reason behind such poor malnourishment figures are manifolds however primary among them are – poor pre and post natal care of womens leading to anaemic women giving birth to under weight babies, lack of public healthcare infrastructure to give proper healthcare services to our citizens.

Malnourishment problem in India

After a decade of conducting National Family and Health Survey – III which had raised a storm due to poor data on malnourishment in India, NFHS-IV preliminary data is out.

The NFHS is commissioned by the Ministry of Health and Family Welfare and carried out by the Mumbai-based International Institute for Population Sciences (IIPS). It is funded by the United States Agency for International Development (USAID) and the government. The first round of NFHS surveying took place in 1992-93, the second round in 1998-99 and the third round in 2005-6.

According to NFHS-IV (2014-15)

Malnourishment has declined by only 5% to 37% of Indian children being stunted.

Decline in wasting of children due to severe malnourishment has declined precipitously to 22% from 33%.

India still accounts for significant number of malnourished children across the world.

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Rate of change in the percentage of underweight children has been negligible in the period 1998-99 to 2005-06 while reduction in wasting of children declined but malnourishment problem remains yawning according to NFHS – IV

Observation from series of NFHS data

The reduction in malnutrition among children has been very slow when compared to rapid economic growth in the post-reform period.

International studies show that the rate of decline in child undernutrition tends to be around half the rate of growth of per capita GDP.

As Angus Deaton and Jean Drèze have said in an article on nutrition, in India’s case, per capita GDP of about 4.2% during 1990 and 2005 was expected to reduce malnutrition by about 2.1% per annum or 27% during this period.

o Compared to this, the decline in malnutrition among children was only 10%.

India has also failed to make progress on reducing anaemia. The proportion of anaemic children aged 6 to 59 months fell just five percentage points to 61% in 2014, and over half of women aged 15-49 are still anaemic. Of all men aged 15-49, a quarter are suffering from anaemia, as was in 2004. Haryana has the highest proportion of anaemic children (72%) and women (63%) while in Bihar and Meghalaya, one in three men are anaemic, the highest in the country.

Sanitation and Knowledge on Malnourishment

The World Bank Policy Research argued that the fact that 25% of stunted Indian children were in the highest wealth quintile reflected the burden of morbidity even among the affluent. WHO estimated that half of malnutrition is attributable to infections arising from poor sanitation, not lack of food.

There are three broad aspects of malnutrition that must be kept in mind when devising strategies for dealing with it

Ability to access such food items. This depends on household income or ability to sustain certain levels of consumption

Family knowledge and information about good nutrition. This includes knowledge about the locally available foods that are good from the nutrition perspective. This knowledge is gained by

i. Traditional Knowledge

ii. Mass Communication – TV, Radio, Newspaper

iii. Literacy – availability of reading material on malnourishment

iv. Special programme like – ICDS

The proportion of stunted children under the age of five has fallen from 48% to 39% between 2005-06 and 2013-14, the new numbers show, meaning that India now has 14.5 million fewer stunted children.

Impact of Govt prog reduce malnourishment

2014 Global Hunger Index report of the International Food Policy Research Institute (IFPRI) shows considerable improvement in India’s hunger index and in the percentage of underweight children — from 24.2 in 2005 to 17.8 in 2014 — an increase of 6.4 points. Also, out of 76 countries, India’s rank improved by around 8 points, from 63 to 55. While India is no longer in the category of “alarming” cases, its hunger status is still classified in the category of “serious”

Improved Stats

Reduction in the percentage of underweight children, from 43.5% in 2005-06 (NFHS-III) to 30.7% in 2013-14

o Remarkable reduction of 13% in eight years during 2005-06 to 2013-14

Impact of economic and agricultural growth

India had a high economic growth of 9% per annum during 2005-06 to 2008-09, which helped in an increase in tax-GDP ratio and an allocation of higher expenditure to the social sector.

Higher agriculture growth rate of 4% per annum during the 11th Plan period (2007-12).

o This too must have helped in raising nutrition.

6% growth during the period 1992-93 to 2005-06 also led to decline in malnutrition during 1992-93 to 1998-99 but there was stagnation in nutrition status during 1998-99 to 2005-06.

o During this phase as well, economic growth and agricultural growth were relatively low.

Improvement in agricultural productivity and growth rate can deliver better outcomes on malnourishment

Ensuring inclusiveness and equity in agriculture that can be achieved by increasing agricultural productivity in rainfed and resource-poor areas.

o This in turn will help raise the productivity and income of small and marginal farmers.

o The bulk of the rural poor, as well as small and marginal farmers, live in such resource-poor areas, where undernutrition is largely prevalent.

Diversify diet in order to improve micronutrients

Agricultural policies to empower women.

Climate change poses a major challenge to agriculture.

This year is the International Year of Family Farming; it needs to be noted that Dr. M.S. Swaminathan has often mentioned the importance of family farming in offering an effective and an economic solution to ensuring that every person has access to nutritious food. Biofortication is one way of having access to micronutrients.

In the last decade, India has improved its health status faster than other South Asian countries, the new data indicates, as opposed to the widespread belief that countries such as Bangladesh had done a better job on reducing malnutrition than India despite India’s faster economic growth.

IFPRI credits the government’s push to extend nutrition schemes

Integrated Child Development Services along with better monitoring by a Supreme Court-appointed committee

Improved access to health under the National Rural Health Mission

Access to work under the National Rural Employment Guarantee Act

o Raised real wages faster than any previous period leading to better living standards in rural areas

Strengthening of implementation of the Public Delivery System for subsidised grain.

o Many states like CG, HP, MP and TN have reformed their PDS achieving better coverage, lower leakage and better awareness among masses for their rights of PDS

Concerns

The biggest concern with the Unicef numbers is that neither are they in the public domain nor have they been accepted by the government internally. This casts a huge doubt about the validity of these numbers

o DLHS 4 Report run counter to the numbers

Even so, India still has the highest number of underweight children under five in the world and 70% of children are anaemic. The proportion of undernourished people in the overall population has fallen from 21.5% in 2004-06 to 17% in 2011-13, according to IFPRI estimates.

Future targets

Post-2005, the development agenda at the global level has, among other things, been focussing on the elimination of hunger and malnutrition. The UN Secretary General recently announced meeting the challenge of ‘Zero Hunger’ — to be achieved by 2025. One of the elements in this challenge is to ensure zero stunted children in less than two years. If this is to be achieved at the global level, then progress in India is important.

Inspite of significant progress in the last eight years, a lot of work has to be done in order to reduce malnutrition in India. This also poses challenges at the global level because figures released by UNICEF show that in 2011, 55 million out of 102 million underweight children under five in the world — or 54% of the global total — live in India. Similarly, 62 million out of 166 million stunted children of the world are from India (37%).

Strategy to deal with Malnutrition

Historically, it has been demonstrated across many countries that public health measures like clean drinking water, sanitation, sewerage, control of communicable and epidemic diseases and public health education play an important role in reducing mortality rates at every age and across gender. In the Indian environment, access to water and toilets, breast feeding (to impart immunity in an unhealthy environment), access to sound health advice/treatment, prevalence of vaccination and availability of vitamin supplements are possible indicators.

India is an outlier in terms of malnutrition in cross-country plots of malnutrition against per capita GDP. Correspondingly, India is way significantly worse than countries at its level of per capita GDP in terms of household access to toilets. It is however close to the trend line with respect to access to improved drinking water source.

Rights of women and children are mutually reinforcing

Malnutrition can be reduced by enhancing women’s health, promoting gender equality and ensuring the empowerment of women including female education. Gender equality and the well-being of children go hand in hand. Gender empowerment is relatively better in Africa. Although poverty and other numbers are higher in South Asia, Africa had a lesser percentage of children under nutrition than South Asia because of better women’s status.

Figures for 2005-06 show that the proportion of children who are underweight is high in States such as Madhya Pradesh (60.3%), Jharkhand (59.2%), Bihar (59%), Chhattisgarh (52%) and Uttar Pradesh (47.3%). Therefore, there is a need to focus on these States.

The consequences of under nutrition are well known.

Stunting and undernutrition are the main contributing factors for child mortality, disability and disease.

There are also the harmful effects of an inadequate intake of specific micronutrients essential for brain development and the nervous system.

o For example, iron deficiency is known to affect a child’s performance in school. In short, “hidden hunger” has to be reduced.

In conclusion, it has to be recognised that ignoring hunger and malnutrition will have significant costs to any country’s development. Nutrition improvement has both intrinsic and instrumental value. Some estimates indicate that there is a 2 to 3% GDP loss due to low productivity. The returns to investments in food and nutrition are quite high. Every dollar spent on interventions to reduce stunting is estimated to generate about $20-$30 in economic returns.

What is Hidden hunger?

If Government give free/ subsidized wheat and rice then hunger will be eliminated only from ‘energy / carbohydrates’ angles.

But Deficiency in micronutrients and vitamins will continue. This is hidden hunger. Every third person in world suffers from Hidden hunger. (total 2 billion)

Why hidden hunger?

During adolescence, pregnancy- higher amount of micronutrient needed but people lack the money / awareness to change died habits accordingly.

China has been successful in increasing agricultural productivity and lifting many out of poverty through introducing right agricultural policies, investments and entrepreneurship. China has achieved significant progress to manage its challenges of food security and been able to halve its global hunger index between 1990 and 2009 steps taken by it in this regard are

Promotion of grain production

Reduction of hoarding and speculation

Strengthening of grain orgs

Development of hybrid pathogen resistant high yield varieties

Brazil’s ‘Bolsa Familia’ (family grant) or Zero Hunger Programme for eradicating food insecurity and eliminating hunger through an integrated set of policies has been backed by a strong political agenda. ‘Bolsa Familia’ involves conditional cash transfers (CCT) to the poorest families in situations of food insecurity if they meet certain requirements like

Children attend school

Vaccination of children

The programme has improved the lives and nutritional intake and has about 12.4 million families enrolled. It has been referred to as a ‘model of effective social policy’ by a former World Bank president. The programme allows children to miss about 15% of classes; if a child gets caught missing more than that, payment is suspended for the entire family. Benefit is often given to mother to ensure proper usage. It involves giving debit card which allows govt. to track all transactions.